Upstate University Hospital Request an Appointment/Referral

Thank you for contacting MD Direct. This is a free and confidential referral service. Based on the information you provide to us, we will provide you with information about our physicians or other providers that best match your needs. If a University Hospital or Upstate Medical University provider does not meet your needs, we will provide you with information about other providers in the community. Physicians and providers do not pay us for a referral or pay to participate in our referral service.

For more information about a department or a physician, please fill out the form below, or call 315-464-4842 or 800-544-1605 to speak with an MD Direct representative. We cannot make appointments on-line through this website, but we will gladly assist in providing you information and a phone number.

(Please do not use this form to send Consult Requests or personal emails to physicians.)

Fields with * are Required

Patient Information

The person who will be seeing the physician.

*Has the patient been seen at Upstate before? Yes No

*First Name:

Middle Initial:

*Last Name:

*Date of Birth: (mm/dd/yyyy)

*Phone Number: (000-000-0000)

Email Address: (someone@somewhere)

Street Address:

City:

State:

Zip Code:

*Insurance Plan: (If no insurance, please enter "NONE")

Contact Person

The person completing this form.

*I am submitting this request for my (If Self, the following can be skipped)